Focus groups to increase the cultural acceptability of a contingency management intervention for American Indian and Alaska Native Communities.

INTRODUCTION: Many American Indian and Alaska Native (AI/AN) people seek evidence-based, cost-effective, and culturally acceptable solutions for treating alcohol use disorders. Contingency management (CM) is a feasible, low-cost approach to treating alcohol use disorders that uses "reinforcers" to promote and support alcohol abstinence. CM has not been evaluated among AI/AN communities. This study explored the cultural acceptability of CM and adapted it for use in diverse AI/AN communities. METHODS: We conducted a total of nine focus groups in three AI/AN communities: a rural reservation, an urban health clinic, and a large Alaska Native healthcare system. Respondents included adults in recovery, adults with current drinking problems, service providers, and other interested community members (n = 61). Focus group questions centered on the cultural appropriateness of "reinforcers" used to incentivize abstinence and the cultural acceptability of the intervention. Focus groups were audio-recorded, transcribed, and coded independently by two study team members using both a priori and emergent codes. We then analyzed coded data. RESULTS: Across all three locations, focus group participants described the importance of providing both culturally specific (e.g., bead work and cultural art work supplies), as well as practical (e.g., gas cards and bus passes) reinforcers. Focus group participants underscored the importance of providing reinforcers for the children and family of intervention participants to assist with reengaging with family and rebuilding trust that may have been damaged during alcohol use. Respondents indicated that they believed CM was in alignment with AI/AN cultural values. There was consensus that Elders or a well-respected community member implementing this intervention would enhance participation. Focus group participants emphasized use of the local AI/AN language, in addition to the inclusion of appropriate cultural symbols and imagery in the delivery of the intervention. CONCLUSIONS: A CM intervention for alcohol use disorders should be in alignment with existing cultural and community practices such as alcohol abstinence, is more likely to be successful when Elders and community leaders are champions of the intervention, the intervention is compatible with counseling or treatment methodologies, and the intervention provides rewards that are both culturally specific and practical.

A Randomized Controlled Trial of Ethyl Glucuronide-Based Contingency Management for Outpatients With Co-Occurring Alcohol Use Disorders and Serious Mental Illness.

OBJECTIVE: The authors examined whether a contingency management intervention using the ethyl glucuronide (EtG) alcohol biomarker resulted in increased alcohol abstinence in outpatients with co-occurring serious mental illnesses. Secondary objectives were to determine whether contingency management was associated with changes in heavy drinking, treatment attendance, drug use, cigarette smoking, psychiatric symptoms, and HIV-risk behavior. METHOD: Seventy-nine (37% female, 44% nonwhite) outpatients with serious mental illness and alcohol dependence receiving treatment as usual completed a 4-week observation period and were randomly assigned to 12 weeks of contingency management for EtG-negative urine samples and addiction treatment attendance, or reinforcement only for study participation. Contingency management included the variable magnitude of reinforcement "prize draw" procedure contingent on EtG-negative samples (<150 ng/mL) three times a week and weekly gift cards for outpatient treatment attendance. Urine EtG, drug test, and self-report outcomes were assessed during the 12-week intervention and 3-month follow-up periods. RESULTS: Contingency management participants were 3.1 times (95% CI=2.2-4.5) more likely to submit an EtG-negative urine test during the 12-week intervention period, attaining nearly 1.5 weeks of additional alcohol abstinence compared with controls. Contingency management participants had significantly lower mean EtG levels, reported less drinking and fewer heavy drinking episodes, and were more likely to submit stimulant-negative urine and smoking-negative breath samples, compared with controls. Differences in self-reported alcohol use were maintained at the 3-month follow-up. CONCLUSIONS: This is the first randomized trial utilizing an accurate and validated biomarker (EtG) to demonstrate the efficacy of contingency management for alcohol dependence in outpatients with serious mental illness.

A culturally-tailored behavioral intervention trial for alcohol use disorders in three American Indian communities: Rationale, design, and methods.

BACKGROUND: Disproportionately high rates of alcohol use disorders are present in many American Indian/Alaska Native (AI/AN) communities, yet little information exists regarding the effectiveness of alcohol treatments in AI/AN populations. Contingency management is an intervention for illicit drug use in which tangible reinforcers (rewards) are provided when patients demonstrate abstinence as assessed by urine drug tests. Contingency management has not been widely studied as an intervention for alcohol problems because until recently, no alcohol biomarker has been available to adequately verify abstinence. AIMS: The HONOR Study is designed to determine whether a culturally-tailored contingency management intervention is an effective intervention for AI/AN adults who suffer from alcohol use disorders. METHODS: Participants include 400 AI/AN alcohol-dependent adults residing in one rural reservation, one urban community, as well as a third site to be decided, in the Western U.S. Participants complete a 4-week lead-in phase prior to randomization, then 12 weeks of either a contingency management intervention for alcohol abstinence, or a control condition where participants receive reinforcers for attending study visits regardless of alcohol use. Participants are then followed for 3-more months post-intervention. The primary study outcome is urinary ethyl glucuronide-confirmed alcohol abstinence; secondary outcomes include self-reported alcohol and drug use, HIV risk behaviors, and self-reported cigarette smoking. DISCUSSION: This will be the largest randomized, controlled trial of any alcohol for AI/ANs and the largest contingency management study targeting alcohol use disorders, thus providing important information to AI/AN communities and the alcohol treatment field in general.

Using ethyl glucuronide in urine to detect light and heavy drinking in alcohol dependent outpatients.

AIMS: This study investigated which ethyl glucuronide immunoassay (EtG-I) cutoff best detects heavy versus light drinking over five days in alcohol dependent outpatients. METHODS: A total of 121 adults with alcohol use disorders and co-occurring psychiatric disorders took part in an alcohol treatment study. Participants provided self-reported drinking data and urine samples three times per week for 16-weeks (total samples=2761). Agreement between low (100 ng/mL, 200 ng/mL), and moderate (500 ng/mL) EtG-I cutoffs and light (women ≤3 standard drinks, men ≤4 standard drinks) and heavy drinking (women >3, men >4 standard drinks) were calculated over one to five days. RESULTS: The 100 ng/mL cutoff detected >76% of light drinking for two days, and 66% at five days. The 100 ng/mL cutoff detected 84% (1 day) to 79% (5 days) of heavy drinking. The 200 ng/mL cutoff detected >55% of light drinking across five days and >66% of heavy drinking across five days. A 500 ng/mL cutoff identified 68% of light drinking and 78% of heavy drinking for one day, with detection of light (2-5 days <58%) and heavy drinking (2-5 days <71%) decreasing thereafter. Relative to 100 ng/mL, the 200 ng/mL and 500 ng/mL cutoffs were less likely to result in false positives. CONCLUSIONS: An EtG-I cutoff of 100 ng/mL is most likely to detect heavy drinking for up to five days and any drinking during the previous two days. Cutoffs of ≥500 ng/mL are likely to only detect heavy drinking during the previous day.